Coronavirus: World still doesn’t understand, Sweden’s COVID-19 expert says

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After three months of non-stop controversy, Sweden’s top epidemiologist is about to go on vacation.

Anders Tegnell is unlikely to stray far from home, after much of the European Union excluded Sweden from safe travel lists. His decision to advise against a Swedish lockdown has coincided with one of the world’s highest COVID-19 mortality rates. But Tegnell insists Sweden’s strategy remains widely misunderstood.

Over the past week, the epidemiologist has made headlines by lashing out at the World Health Organization and labeling as “mad” countries that opted for strict lockdowns.

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Throughout it all, Tegnell has argued that the world is only in the first stage of dealing with a long, uncertain battle with COVID-19. That’s why Sweden’s strategy -- keep much of society open, but train people to observe distancing guidelines -- is the only realistic way to cope in the long run, he says.

“I’m looking forward to a more serious evaluation of our work than has been made so far,” Tegnell said in a podcast published by Swedish public radio. “There is no way of knowing how this ends.”

Swedish victory

On Friday, Tegnell won a very public victory against the WHO, after lambasting the organization for making a “total mistake.” The WHO named Sweden on a list of 11 European countries where it said “accelerated transmission has led to very significant resurgence that, if left unchecked, will push health systems to the brink.” While Sweden remains on the list available on the WHO’s website, the organization has amended its assessment, and said Swedish contagion rates are in fact “stable.” It linked the high number of cases to an increase in testing.

William Hanage, associate professor of epidemiology at Harvard’s School of Public Health in Boston, said, “Sweden’s policy is unusual in that it took a much less stringent approach to preventing transmission, but interestingly it implemented those measures at a very early stage in the pandemic, before large amounts of community spread had occurred.”

“Sweden’s approach may be sustainable in ways other countries’ have not proven to be,” according to Hanage. “It should be noted that lockdowns are a response to an imminent surge into health care, with the goal of stopping as many transmission chains as quickly as possible. The full accounting will only be possible after the pandemic.”

But the Swedish approach has come at a cost, and its death toll per 100,000 is now five times that in neighboring Denmark, according to Johns Hopkins University data. The strict lockdown the Danes imposed in mid-March has since been wound back after the virus was ostensibly brought under control.

In Sweden, it is “bluntly not clear how the vulnerable are expected to be protected,” Hanage said. “Once you get a very large outbreak in one age group, it becomes more difficult to protect others.” It’s a scenario that has played out bleakly in Sweden’s nursing homes, where the death rate has been brutally high, prompting at least one criminal investigation.

In an interview with Dagens Nyheter, Tegnell said he’s not sure he would have imposed a stricter lockdown in Sweden with the benefit of hindsight, seeming to walk back a view he has previously articulated.

“Maybe. I don’t know,” he said. “But you have to consider whether there are other tools that work just as well.”

Lockdown cost

Tegnell’s main concern is that strict lockdowns may temporarily contain the virus, but won’t prevent it from returning. He also says lockdowns come at an avoidable cost.

“In the same way that all drugs have side effects, measures against a pandemic also have negative effects,” he said. “At an authority like ours, which works with a broad spectrum of public health issues, it is natural to take these aspects into account.” He lists domestic abuse, loneliness and mass unemployment.

In its emailed comment on Friday, the WHO said “there are several very positive trends in Sweden, notably, a continued decrease in new cases presenting with severe disease, a gradual decrease in patients admitted into intensive care since April, and continued decreasing numbers of new COVID-19 deaths.”

“Sweden has involved the community in the response, and has been able to keep transmission to levels that can be managed by the Swedish health system,” the organization said.

Time will tell

Ultimately, it’s too early to know which model is the smartest when dealing with the current pandemic.

“Sweden’s approach has been widely misrepresented as doing nothing. It’s not,” Hanage said. “Given a starting point in which it has been decided an outbreak is inevitable, the question becomes how to mitigate it and preserve health care, and the earlier on in the outbreak you take action to slow transmission, the less intense that action needs to be -- initially.”

“Sweden’s strategy, in that sense, has been smarter than those countries’ that encouraged transmission until shutdowns became necessary,” Hanage said. “However, it has come at a great cost in terms of mortality in vulnerable groups … It also needs to be flexible and responsive; if a surge is building, you need to be able to detect it and know what you will do to avert it.”

“As for the overall outcome,” Hanage said, “time will tell.”

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